Patient Navigator, Care Management

Job Summary

Under the direction of the Manager of Care Management, the Patient Navigator will proactively manage health center populations with chronic conditions and those in need of follow up for acute conditions. The Patient Navigator will work closely with the members of the Care Management team to ensure the delivery of evidence-based care through a team-based, patient centered medical home approach. The Patient Navigator will address gaps in care through outreach to patients in need of routine screening and/or chronic disease management, schedule appointments, and/or enter outside data to close gaps to improve patient care and achieve quality performance goals.


  • Bachelor’s Degree strongly preferred, may be substituted for years of relevant experience
  • Experience working in healthcare setting with patient-focused experience preferred
  • Bilingual in Spanish or Albanian preferred


Representative Job Duties

Patient outreach and engagement

  • Tracks patients with diabetes, abnormal cervical cancer screening, and abnormal breast cancer screening results to support their care management.
  • Identifies and outreaches to patients in need of screening and follow up test such as HgbA1C, pap smear, and mammograms.
  • Enters results of lab test and procedures in the EHR and works with providers and Care Management Nurses to notify patient’s of results.
  • Manages lists of patients in Microsoft Excel and via the EHR to track and follow up with patients
  • Provides data entry and support to the primary care and care management departments.
  • Assists with patient care services such as education, referral coordination, and transportation.
  • Enrolls patients in the patient portal.
  • Communicates effectively, efficiently, and professionally over the phone with patients.


Performance Improvement

  • Monitors progress on quality measures related to diabetes, cervical cancer screening, and breast cancer screening.
  • Improves patient care and data quality by entering external results in structured data fields in the EHR to record clinically relevant patient care performed outside of the health center.
  • Actively works to identify opportunities for improvement in workflows to improve population health and provides constructive ideas, suggestions, and feedback in a positive manner.
  • Coordinates with Clinical Quality Analyst and Director of Performance Improvement to promote quality throughout the health center and troubleshoot areas of concern.


Health Center Participation

  • Provides consistent, reliable and excellent customer service internally and externally.
  • Contributes to the team effort by supporting all staff members and maintaining an open and positive attitude.
  • Adheres to all health center and departmental policies and procedures.
  • Attends all required meetings.
  • Participates in additional quality assessment and improvement activities as requested.


Assumes other duties as requested

Skills and Abilities

  • Highly motivated and mission-driven
  • Highly organized and self-motivated individual with the ability work autonomously
  • Mature, professional, dependable
  • Ability to work independently as well as part of a team
  • Collaborative working style with the ability to work with staff across different departments, teams, and roles.
  • Ability to communicate effectively with diverse staff and patients
  • Warm and professional telephone manner
  • Excellent written communication skills
  • Excellent critical thinking skills
  • Superior organizational skills and follow-through
  • Ability to balance multiple projects, prioritize effectively, and follow up to complete tasks
  • Ability to learn HIPAA and adhere to data security best practices


*The statements above are intended to describe the general nature and level of work being performed by staff members in this role; they are not intended to be an exhaustive list of all responsibilities and duties required.

Competitive benefits package.  Generous tuition assistance available after 1 year of service.

Please send resumes to:

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